Provider Demographics
NPI:1346665858
Name:FISK, MELISSA (BSW, QIDP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:FISK
Suffix:
Gender:F
Credentials:BSW, QIDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 40TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-6084
Mailing Address - Country:US
Mailing Address - Phone:616-889-1607
Mailing Address - Fax:616-241-6470
Practice Address - Street 1:1111 40TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-6084
Practice Address - Country:US
Practice Address - Phone:616-889-1607
Practice Address - Fax:616-241-6470
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802087523104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker